Chronic Obstructive Pulmonary Disease (COPD) Measures Document

Chronic Obstructive Pulmonary Disease (COPD) Measures Document COPD Version: 3 - covering patients discharged between 01/10/2017 and present. Programme Lead: Jo Higgins Clinical Lead: Dr Paul Albert Number of Measures In Clinical Focus Area (CFA) Clinical Process Measures 5 Data Measures - Mandatory 1 Email: advancing.quality@nhs.net Website: http://www.advancingqualitynw.nhs.uk Produced on 21 June 2017

Introduction Chronic Obstructive Pulmonary Disease (COPD) is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. People with COPD have difficulties breathing, primarily due to the narrowing of their airways, this is called airflow obstruction. COPD is characterised by airflow obstruction that is not fully reversible. The airflow obstruction does not change markedly over several months and is usually progressive in the long term. COPD is predominantly caused by smoking. Other factors, particularly occupational exposures, may also contribute to the development of COPD. The airflow obstruction is present because of a combination of airway and parenchymal damage. The damage is the result of chronic inflammation that differs from that seen in asthma and which is usually the result of tobacco smoke. Significant airflow obstruction may be present before the person is aware of it. COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on the airflow obstruction. Exacerbations often occur, where there is a rapid and sustained worsening of symptoms beyond normal day-to-day variations. COPD is one of the most common respiratory diseases in the UK. It usually only starts to affect people over the age of 35, although most people are not diagnosed until they are in their 50s. It is thought there are more than 3 million people living with the disease in the UK, of which only about 900,000 have been diagnosed. This is because many people who develop symptoms of COPD do not get medical help because they often dismiss their symptoms as a smoker s cough. Although COPD causes about 25,000 deaths a year in the UK, severe COPD can usually be prevented by making lifestyle changes (NHS Choices). The Advancing Quality COPD measures have been chosen to prompt early recognition and treatment of patients admitted to hospital as an emergency with a COPD exacerbation. The expected outcome is to reduce premature mortality. Page 2

Measures In Clinical Focus Area Measure Type Measure ID Clinical Process Measure Data Measure - Mandatory COPD-01 COPD-02 COPD-03 COPD-04 COPD-05 COPD-06 Measure Name Oxygen prescribed and administered within 4 hours of hospital arrival Corticosteroids administered within 4 hours of hospital arrival Bronchodilators administered within 4 hours of hospital arrival Offer smoking cessation advice Review inhaler technique Non-invasive ventilation considered if indicated Page 3

Measure ID: Measure Name: COPD-01 Unique Record Identifier: 10061600 Measure Description: Oxygen prescribed and administered within 4 hours of hospital arrival COPD patients should have oxygen prescribed and administered within 4 hours of hospital arrival. Measure Type: Clinical Process Measure Rationale: An effective treatment to increase the amount of oxygen in the arterial blood to a safe level. Prescribed oxygen as recommended by NICE for those at risk of developing type II respiratory failure. Patients with COPD, especially those who receive high oxygen flow oxygen, are at high risk of hypercapnia leading to type II respiratory failure. In the management of acute exacerbations the options for targeted oxygen prescription are 88-92% or 94-98% or should be administered in line with hospital trust guidelines and policy. Numerator Statement: Number of patients who have had oxygen prescribed and administered within 4 hours of hospital arrival. Denominator Statement: Number of patients who are eligible to have oxygen prescribed and administered within 4 hours of hospital arrival. Measure Reported As: The percentage of eligible patients that had their oxygen prescribed and administered within 4 hours of hospital arrival. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Clinical Trial COPD COPD Diagnosis Discharge - within 4 hours Oxygen - administered within 4 hours Oxygen - indicated COPD Oxygen - prescribed Oxygen - saturations performed Palliative Care within 4 hours COPD Transfer from another A&E Dept COPD Measure Exclusions: Documentation in the medical record, by a consultant (or person working as part of the consultant team) that the patient is for palliative care only within 4 hours of arrival Documentation in the medical record that the patient participated in a clinical trial affecting care or treatment related to this AQ measure set Documentation in the medical record that the patient was transferred from another hospital A&E department Documentation in the medical record that the patient left the hospital within 4 hours of arrival Documentation within the medical record that oxygen was not indicated No documentation in the medical record, as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient, that the final diagnosis/impression was of COPD. Page 4

Measure ID: Measure Name: COPD-02 Unique Record Identifier: 10062200 Measure Description: Corticosteroids administered within 4 hours of hospital arrival COPD patients should have corticosteroids administered within 4 hours of hospital arrival. Measure Type: Clinical Process Measure Rationale: An effective treatment to prevent or reduce the symptoms of COPD during exacerbation as recommended by NICE. Corticosteroids should be administered in line with local Hospital Trust guidelines and policy. Numerator Statement: Number of patients that have had corticosteroids administered within 4 hours of hospital arrival. Denominator Statement: Number of patients eligible to have corticosteroids administered within 4 hours of hospital arrival. Measure Reported As: The percentage of eligible patients who received corticosteroids within 4 hours of hospital arrival. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Arrival Date COPD Arrival Time COPD Clinical Trial COPD COPD Diagnosis Corticosteroids - reason Corticosteroids Date COPD Corticosteroids Time Discharge - within 4 hours Palliative Care within 4 hours COPD Transfer from another A&E Dept COPD Measure Exclusions: Documentation in the medical record, by a consultant (or person working as part of the consultant team) that the patient is for palliative care only within 4 hours of arrival Documentation in the medical record that the patient participated in a clinical trial affecting care or treatment related to this AQ measure set Documentation in the medical record that the patient was transferred from another hospital A&E department Documentation in the medical record that the patient left the hospital within 4 hours of arrival There is documentation of one or more potential contraindications/reasons for not prescribing a corticosteroid within four hours of hospital arrival. No documentation in the medical record, as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient, that the final diagnosis/impression was of COPD. Page 5

Measure ID: Measure Name: COPD-03 Unique Record Identifier: 10062300 Measure Description: Bronchodilators administered within 4 hours of hospital arrival COPD patients should have bronchodilators administered within 4 hours of hospital arrival. Measure Type: Clinical Process Measure Rationale: An effective treatment to prevent or reduce the symptoms of COPD as recommended by NICE. Bronchodilators should be administered in line with local Hospital Trust guidelines and policy. Numerator Statement: Number of patients that have had bronchodilators administered within 4 hours of hospital arrival. Denominator Statement: Number of patients eligible to have bronchodilators administered within 4 hours of hospital arrival. Measure Reported As: The percentage of eligible patients who received bronchodilators within 4 hours of hospital arrival. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Arrival Date COPD Arrival Time COPD Bronchodilator - reason Bronchodilator Date Bronchodilator Time Clinical Trial COPD COPD Diagnosis Discharge - within 4 hours Palliative Care within 4 hours COPD Transfer from another A&E Dept COPD Measure Exclusions: Documentation in the medical record, by a consultant (or person working as part of the consultant team) that the patient is for palliative care only within 4 hours of arrival Documentation in the medical record that the patient participated in a clinical trial affecting care or treatment related to this AQ measure set Documentation in the medical record that the patient was transferred from another hospital A&E department Documentation in the medical record that the patient left the hospital within 4 hours of arrival Documentation In the medical record of a reason/contraindication for not prescribing a bronchodilator within 4 hours of hospital arrival No documentation in the medical record, as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient, that the final diagnosis/impression was of COPD. Page 6

Measure ID: Measure Name: COPD-04 Offer smoking cessation advice Unique Record Identifier: 10062500 Measure Description: COPD patients should be offered smoking cessation advice. This should be during hospitalisation. Measure Type: Clinical Process Measure Rationale: Half of all long-term smokers die early from smoking-related diseases. Men who quit smoking by 30 add 10 years to their life. People who quit at 60 add three years to their life. Stopping smoking can halt progression of COPD. (NHS Choices) The definition of a current smoker includes daily smokers and non-daily smokers (also known as occasional smokers) or anyone who has smoked within the last year. People with COPD who smoke are regularly encouraged to stop and are offered the full range of evidence-based smoking cessation support. Numerator Statement: Number of patients offered smoking cessation advice. Denominator Statement: Number of patients eligible to be offered smoking cessation advice. Measure Reported As: The percentage of eligible patients that were offered smoking advice. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Clinical Trial COPD COPD Diagnosis Discharge - within 4 hours Palliative Care within 4 hours COPD Smoker - current COPD Smoking - offer advice Measure Exclusions: Documentation in the medical record, by a consultant (or person working as part of the consultant team) that the patient is for palliative care only within 4 hours of arrival Documentation in the medical record that the patient participated in a clinical trial affecting care or treatment related to this AQ measure set Documentation in the medical record that the patient left the hospital within 4 hours of arrival No documentation in the medical record that the patient smoked within the last 12 months, or unable to determine from the medical record No documentation in the medical record, as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient, that the final diagnosis/impression was of COPD. Page 7

Measure ID: Measure Name: COPD-05 Review inhaler technique Unique Record Identifier: 10063700 Measure Description: COPD patients should have their inhaler technique reviewed prior to discharge Measure Type: Clinical Process Measure Rationale: The correct technique when taking inhaled medications ensures that patients with chronic obstructive pulmonary disease receive the maximum benefit from their medications. Inhaler technique is a clinical assessment of how well a patient is able to use and administer their inhaled medication. This should be witnessed and documented by a clinical member of staff. Numerator Statement: Number of patients who have had their inhaler technique reviewed. Denominator Statement: Number of patients eligible to have their inhaler technique reviewed. Measure Reported As: The percentage of patients that have their inhaler technique reviewed. Improvement Noted As: An increase in the rate. Data Elements: To be considered complete the following data elements should be recorded for the measure:- Clinical Trial COPD COPD Diagnosis Discharge - within 4 hours Inhaler - already on Inhaler - technique reviewed COPD Palliative Care within 4 hours COPD Measure Exclusions: Documentation in the medical record, by a consultant (or person working as part of the consultant team) that the patient is for palliative care only within 4 hours of arrival Documentation in the medical record that the patient participated in a clinical trial affecting care or treatment related to this AQ measure set Documentation in the medical record that the patient left the hospital within 4 hours of arrival No documentation in the medical record that the patient is already on an inhaler therapy No documentation in the medical record, as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient, that the final diagnosis/impression was of COPD. Page 8

Measure ID: Measure Name: COPD-06 Non-invasive ventilation considered if indicated Unique Record Identifier: 10065000 Measure Description: COPD patients should have non-invasive ventilation (NIV) considered if indicated Measure Type: Data Measure - Mandatory Rationale: This data collection measure is only relevant in patients where an ABG was performed. Non-invasive ventilation (NIV) is an alternative to invasive mechanical ventilation for patients who have chronic respiratory insufficiency or respiratory failure and can no longer breathe adequately on their own. NIV provides ventilatory support to a patient through the upper airways. It enhances the breathing process by giving the patient a mixture of air and oxygen from a flow generator through a tightly fitted facial or nasal mask. NIV assists the patient in taking a full breath and helps to maintain an adequate oxygen supply to the body. NIV can provide a safe and effective alternative at an early stage of respiratory failure and provide for gradual weaning and normal eating and communication The benefits of an acute NIV service are likely to be: -Fewer patients referred to intensive care for intubation. -Shorter stays on intensive care. -Fewer deaths of patients with acute respiratory failure. Numerator Statement: Number of patients who were considered for NIV if indicated Denominator Statement: Number of patients who were eligible to be considered for NIV if indicated Measure Reported As: Percentage of patients who were considered for NIV if indicated Data Elements: To be considered complete the following data elements should be recorded for the measure:- ABG - abnormal result ABG - within 4 hours Clinical Trial COPD COPD Diagnosis Discharge - within 4 hours NIV - considered COPD Palliative Care within 4 hours COPD Transfer from another A&E Dept COPD Measure Exclusions: Documentation in the medical record, by a consultant (or person working as part of the consultant team) that the patient is for palliative care only within 4 hours of arrival Documentation in the medical record that the patient participated in a clinical trial affecting care or treatment related to this AQ measure set Documentation in the medical record that the patient was transferred from another hospital A&E department No documentation in the medical record that arterial blood gases (ABG) were completed within 4 hours prior to or after arrival at hospital Documentation in the medical record that the patient left the hospital within 4 hours of arrival No documentation in the medical record that the patients arterial blood gases were abnormal. Page 9

No documentation in the medical record, as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient, that the final diagnosis/impression was of COPD. Page 10

Appendices I. Data Elements Required for Clinical Focus Area Data Element Definition Source Collected for Measures ABG - abnormal result Documentation in the medical record that the patient had an abnormal arterial blood gas (ABG) result. ABG - within 4 hours Arrival Date COPD Arrival Time COPD Bronchodilator - reason Bronchodilator Date Bronchodilator Time Clinical Trial COPD COPD Diagnosis Corticosteroids - reason Corticosteroids Date COPD Corticosteroids Time Discharge - within 4 hours Inhaler - already on Documentation in the medical record that an arterial blood gas (AGB) test was performed within 4 hours of arrival. The earliest documented date (dd/mm/yyyy) that the patient arrived at the hospital for this spell of care/treatment. The earliest documented time (hh:mm) (24 hour clock) the patient arrived at the hospital. Documentation in the medical record of one of more potential reasons/contraindications for not prescribing a bronchodilator. The earliest date (dd/mm/yyyy) that a bronchodilator was administered. The earliest time (hh:mm) (24 hour clock) that a bronchodilator was administered. Documentation in the medical record that the patient was involved in a clinical trial during this hospital stay, directly affecting AQ Measures (specific to the AQ clinical condition the patient was treated for during this spell of care/treatment). Clinical trials are organised studies to provide large bodies of clinical data for statistically valid evaluation or treatment. These studies are usually rigorously controlled tests of new drugs, invasive medical devices, or therapies on human subjects. Documentation in the medical record as part of A&E, MAU or post-take ward round documentation, or as an admission diagnosis/impression for a direct admit patient, that the final diagnosis/impression was of COPD. Documentation in the medical record of one or more potential reasons/contraindications for not prescribing corticosteroids. The earliest documented date (dd/mm/yyyy) that corticosteroids were administered. The earliest documented time (hh:mm) (24 hour clock) that corticosteroid was administered. It is documented in the medical record that the patient was discharged from the hospital within 4 hours of arrival. Documentation in the medical record that the patient is on inhaler therapy. Hospital data collection COPD-06 COPD-06 COPD-02, COPD-03 COPD-02, COPD-03 COPD-03 COPD-03 COPD-03 COPD-01, COPD-02, COPD-03, COPD-04, COPD-05, COPD-06 COPD-01, COPD-02, COPD-03, COPD-04, COPD-05, COPD-06 COPD-02 COPD-02 COPD-02 COPD-01, COPD-02, COPD-03, COPD-04, COPD-05, COPD-06 COPD-05 Inhaler - technique Documentation in the medical record that the COPD-05 Page 11

reviewed COPD patient received an inhaler technique review. NIV - considered COPD Oxygen - administered within 4 hours Oxygen - indicated COPD Oxygen - prescribed Oxygen - saturations performed Palliative Care within 4 hours COPD Smoker - current COPD Documentation in the medical record that the patient was considered for non-invasive ventilation. Documentation in the medical record that oxygen was administered within 4 hours. Documentation in the medical record that oxygen was indicated Documentation in the medical record that oxygen was prescribed. Documentation in the medical record that an oxygen saturation test was performed. Consultant (or person working as part of the consultant team) documentation of palliative care. Palliative care includes attention to the psychological and spiritual needs of the patient and support for the dying patient and the patient's family. It may also be known as advanced care planning or advance care plan in place. Documentation in the medical record that the patient smoked tobacco anytime during the 12 months prior to hospital arrival. Smoking - offer advice Documentation in the medical record that the patient (or carer) was offered smoking cessation advice. Transfer from another A&E Dept COPD Documentation in the medical record that the patient was transferred from another hospital A&E department. COPD-06 COPD-01 COPD-01 COPD-01 COPD-01 COPD-01, COPD-02, COPD-03, COPD-04, COPD-05, COPD-06 COPD-04 COPD-04 COPD-01, COPD-02, COPD-03, COPD-06 Page 12

II. Population Identification Criteria with Codes The COPD cohort consists of admitted inpatients with a first episode primary ICD-10 diagnosis code of J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection and J44.1 - Chronic obstructive pulmonary disease with acute exacerbation, unspecified Patient classification - 1 Admission method - non elective Excluded - Admission source 51,52,53 Patients >= 18 years old Page 13

III. References Bestall, J.C., Paul, E.A., Garrod, R. et al. (1999) Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease. Thorax 54(7), 581-6. Bourbeau, J., Julien, M., Maltais, F. et al. (2003) Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention. Archives of Internal Medicine 163(5), 585-91. Celli, B.R. (2000) The importance of spirometry in COPD and asthma: effect on approach to management. Chest 117(2 Suppl), 15S-9. Cully, J.A., Graham, D.P., Stanley, M.A. et al. (2006) Quality of life in patients with chronic obstructive pulmonary disease and comorbid anxiety or depression. Psychosomatics 47(4), 312-9. Gallefoss, F. and Bakke, P.S. (2002) Cost-benefit and cost-effectiveness analysis of self-management in patients with COPD--a 1-year follow-up randomized, controlled trial. Respiratory Medicine 96(6), 424-31. Global Initiative for Chronic Obstructive Lung Disease (2006) Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. Global Initiative for Chronic Obstructive Lung Disease. Heffner, J.E., Mularski, R.A. and Calverley, P.M. (2010) COPD performance measures: missing opportunities for improving care. Chest 137(5), 1181-9. Kunik, M.E., Roundy, K., Veazey, C. et al. (2005) Surprisingly high prevalence of anxiety and depression in chronic breathing disorders. Chest 127(4), 1205-11. National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update of CG12) (full NICE guideline). Clinical guideline 101. National Institute for Health and Clinical Excellence. NHS Scotland (2010) Palliative care in advanced lung disease. NHS Lothian. Robb, E., Jarman, B., Suntharalingam, G. et al. (2010) Using care bundles to reduce in-hospital mortality: quantitative survey. BMJ (Clinical Research Ed) 340, c1234. Royal College of Physicians of London, British Thoracic Society and British Lung Foundation (2008) Report of the National Chronic Obstructive Pulmonary Disease Audit 2008: clinical audit of COPD exacerbations admitted to acute NHS units across the UK. Royal College of Physicians of London. Sullivan SD, Ramsey, S.D. and Lee, T.A. (2000) The economic burden of COPD. Chest 117(2 Suppl), 5S-9. Page 14

IV. Algorithms Page 15

Page 16

Page 17

Page 18

Page 19

Page 20

Page 21

Page 22

Page 23

COPD: Advancing Quality Data form Name: Hospital Number: DOB: / / NHS: Ethnicity: Source of Admission Admission Date & Time / / : Discharge Date / / Discharge Destination Discharge Method EXCLUSIONS 1. Palliative care within 4 hours of arrival Yes No If Yes, stop 2. Clinical trial Yes No If Yes, stop 3. Discharged within 4 hours of arrival Yes No If Yes, stop 4. Transferred from another A&E Yes No If Yes, skip 5-14, 19-21 5. Arrival date & time / / : 6. COPD diagnosis: by A&E/Post take/direct AD Yes No If no, stop OXYGEN THERAPY 7. Oxygen saturations performed Yes No 8. Oxygen indicated (as per local policy) Yes No If no, skip 9&10 9. Oxygen prescribed Yes No If no, skip 10 10. Oxygen administered within 4 hours Yes No CORTICOSTEROIDS 11. Reason documented for not administering corticosteroids Yes No If Yes, skip 12 12. Date & time first corticosteroids administered / / : SMOKING CESSATION 15. Smoked within the last 12 months Yes No If No, skip 16 16. Offered smoking cessation advice Yes No INHALER TECHNIQUE 17. On Inhaler Therapy Yes No If No, skip 18 18. Inhaler technique reviewed Yes No DATA COLLECTION ONLY: NIV CONSIDERED 19. ABG performed within 4 hours Yes No If no, skip 20&21 20. Abnormal ABG result ph < 7.35 PCO2 >6.5 Yes No If no, skip 21 21. NIV considered Yes No VALIDATIONS Form completed by Designation Inputted by Date Inputted / / BRONCHODILATORS 13. Reason documented for not administering bronchodilators Yes No If Yes, skip 14 14. Date & time bronchodilators administered / / : COPD DATA COLLECTION FORM v4.1 Page 24